Accredited Social Health Activists (ASHA) workers are community health workers instituted by the Ministry of Health and Family Welfare under the National Rural Health Mission in 2005. They act as a link between the community and the public health system.
- ASHA workers play a crucial role in promoting health and wellness at the grassroot level.
- However, they face many challenges that impact their productivity and effectiveness.
Key Responsibilities & Importance
- Spread awareness on best health practices & promote behavior change communication
- Counsel women on birth preparedness, importance of safe delivery, breastfeeding, immunization
- Accompanying children & women in Villages to health centers for care
- Maintain records of pregnant women, births, deaths, children’s weight etc.
ASHA workers are the backbone of rural healthcare as they are the first point of contact for any health related demands of deprived sections of population. Their importance has been reiterated time and again by policy makers and experts.
Challenges Faced
Irregular Income & Payments
- Average monthly income of ASHA workers is low and erratic, ranging from Rs. 1000-4000 per month only
- Leads to demotivation and high attrition
- Often subjected to delays in incentives and remunerations
- Delays ranging from few months to over a year
- Eg. Maharashtra ASHA workers on strike in Dec 2023 over payment delays
Inadequate Training
- Minimal pre-work training before deployment
- Only undergo 23 days of classroom & field-based trainings
- Refresher trainings are inadequate
- 85.6% workers reported not receiving any refresher training as per a 2021 study
- Impacts their skills and efficiency in handling responsibilities
Lack of Career Growth & Poor Social Recognition
- No formal service-related entitlements or social security benefits provided
- Have limited scope for career development and growth
- Not adequately valued within the health system hierarchy
- Seen more as volunteers than formal health workers
This further demotivates them and causes high drop-out rates of over 8%, as per the latest government data.
Safety & Infrastructure Issues
- Often expected to travel long distances alone without arrangements for security
- Exposes them to safety hazards
- Not provided adequate kits, registers, medicines etc. to perform duties
Work Overload & Mental Health Issues
- Handle multiplicity of activities – increasing administrative work adds to burden
- No structured guidelines for workload management
- Constant availability for community needs leads to burnout & mental stress
As per a 2020 study, over 75% ASHAs workers were at risk for severe depression.
Government Initiatives & Developments
The government has introduced some measures to empower and support ASHA workers:
Incentives & Payments
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- Union Budget 2023-24 provisioned ₹ 2,412 crore for ASHA package incentives
- Mandated timely monthly payment through Direct Benefit Transfer (DBT)
Expanded Roles under Ayushman Bharat
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- Incentives introduced for creating awareness on AB-PMJAY health insurance scheme
- Will get payment for making referrals & follow-ups using IT platform
Boosting Training & Skills
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- ‘ASHAs Soft Skills Training’ launched in 20 states to enhance communication capabilities
- States asked to utilize National Health Mission funds for training ASHAs using digital media
Social Security Cover
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- ASHA workers included under Pradhan Mantri Shram Yogi Maan-dhan pension scheme
However, more robust policy measures need to be designed and implemented to address core challenges outlined earlier.
Key Gaps Existent
Absence of Employee Status
- Continue to be classified as volunteers – impedes the formalization of their role
- They are not recognized as permanent employees or given licenses to practice
- Hampers the provision of fair remuneration, structured career progression and social security benefits
Lack of Effective Grievance Redressal Avenues
- No established mechanisms for ASHAs to voice concerns about delayed payments, safety issues, excess workloads etc.
Need for Workload & Performance Monitoring
- No standard guidelines formulated till date outlining:
- Optimum patient coverage and visiting schedules
- Realistic activity mix aligned with incentives
- indicators to track ASHA worker performance
- Leads to overburdening and variable effectiveness across states
Key Statistics
- Total no. of ASHA workers currently:4 lakhs
- Presence in no. of Gram Panchayats:5 lakhs
- Women as a % share of total workers: over 95%
- Average Monthly Incentives as of March 2023: ₹ 3176
- Attrition Rate of ASHAs from role: estimated 8.2%, last verified in 2020
Case Studies
Andhra Pradesh has implemented technology-led initiatives to empower ASHAs which involve:
- Mobile-based real-time tracking of activities
- Cashless payment of incentives through electronic transfers
- Chat-based grievance redressal mechanism called ‘Samvadam’
These have digitized their work flows and boosted efficiency.
Whereas Odisha has taken steps towards enhancing career progression of ASHAs by enabling:
- Initial recruitment as Community Health Officers (CHOs)
- Advancement opportunity as health supervisors after 5 years of work
Such professional development has improved motivation levels.
Way Forward
Empowering ASHA workers is vital considering their role as change agents influencing rural health access. They form the nexus between government health machinery and marginalized communities.
- While policies to uplift them have gradually been strengthened, more still needs to be done.
- Institutionalizing workforce management frameworks clearly delineating workloads, job descriptions and payment protocols can improve ease of governance.
- Platforms for voicing concerns and tracking deliverables need to be locally enacted, keeping regional/state variations in consideration.
- Mechanisms for skill development, career mapping, insurance coverage and old age pensions also need to be part of a comprehensive strategy to nurture this critical workforce.
- With upcoming policies like the National Health Workforce Accountability Framework focusing strongly on addressing human resource challenges, there is hope on the horizon.
- But concentrated action in consultation with workers themselves remains the need of the hour.